Considering a TPA to administer your health plan? Ask these 8 questions first

This article was published on August 7, 2018 on Employee Benefit News, written by Corte Larossi.

We all know that making changes to your health plan can have major consequences for your company. It can impact your medical costs and company bottom line, the health and welfare of your employees, employee satisfaction and performance, as well as your ability to hire and retain high performing staff. If your health plan is currently self-funded — or you are considering moving to a self-funded arrangement — the stakes can be even higher since you’re responsible for part or even all the medical costs, depending on the size of your company and risk tolerance.

One of the most critical functions is the administration of your medical claims. Your claims payer — whether a traditional insurance carrier or a third-party administrator — can help make or break the success of a self-funded plan. Many times, these entities also will provide other services directly, or through strategic partnerships including pharmacy benefits management, medical management, stop-loss, employee and provider portal access, voluntary products and telemedicine — just to name a few.

For many small to medium-size employers (25-1,000 employees), and even some larger companies, a TPA may be a good option. The advantage of the traditional carriers is often the medical claim discounts they offer along with nationwide access, which is clearly important, but they might not provide the flexibility smaller employers may need to meet their plan objectives. Additionally, some carriers do allow TPAs to access their networks, which can provide TPA clients deeper savings than may be available through rental PPOs.

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Photo Source: Employee Benefit News

Here are eight important questions employers should ask when vetting TPA partners.

1. What is their claims administration platform?

This is one of the most critical issues when choosing a TPA. Do they have an older legacy system that may be less flexible, or are they using a platform that provides the ability to manage newer, more sophisticated products? Also, can they adjudicate a high volume of claims on an automated basis, or is the process more manual? This is not to say that manual processing isn’t necessary since there could be plan nuances and exceptions that need to be addressed outside of the standard adjudication process. But in general, the higher degree of automation, the more cost effective the process for both the TPA and the client.

Can they easily and accurately manage service/provider carve outs or additions? What is their process and commitment to meeting your objectives? Can they administer other types of services including, but not limited to dental, vision, HRAs, HSAs, COBRA, subrogation and COB? Continue reading

Who Owns Your Claims Data?

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You Can’t Manage What You Don’t Measure!

With a self-funded healthcare plan and a good, independent TPA, access to claims data is standard operating procedure. Even more important, a good TPA like Diversified Group has the expertise to convert your data into intelligent, actionable strategies to manage your plan, monitor performance and modify plan design to control costs.

In contrast, employers with fully insured health plans seldom see their claims data. Even self-funded plans managed by large carrier-owned ASO divisions are often unable to receive claims data on a regular basis.

Analyzing claims data with state-of-the-art tools helps identify, analyze and manage potentially high dollar claims. This capability alone saves many of our clients more than 20% annually. Hospital stays can be monitored, claim costs can be unbundled to detect fraud and abuse and discounts can be negotiated without compromising the quality of care received. Even the rising cost of specialty (bio-tech) pharmaceuticals can be managed when risks are identified early on.

If you’re not receiving claims data and analysis, you’re operating in the dark and it’s time you had a conversation with your broker or TPA. After self-funding your health plan, we consider analyzing claims data to be “Cost Control 101”!

Tell Us How You Feel!

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Bringing Forward Thinking and Transparency to Employee Benefits

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Diversified Group continues its efforts to bring a revolutionary perspective and innovation to employee healthcare. With the recent launch of our monthly email newsletter, Healthcare Uncensored, we are attempting to break down the walls of healthcare complexity and shed light on the confusing state of employee health benefits. Each issue addresses and openly discusses a particular trend or pressing issue that is having great impact on employers and plan members.

“Real change in the world of health benefits won’t happen unless everyone – employers, brokers, providers and consumers – gets involved,” said Brooks Goodison, President of Diversified Group.

By encouraging all to join the conversation and asking questions most are afraid to address, we are paving the way for true healthcare transparency and trying to provide real solutions to the employee benefit concerns of many.

We are proud to say that our efforts are not going unnoticed. Earlier this month, Diversified Group was recognized by The Phia Group with the 2018 Empowered Plans Award at its annual MVP (Most Valuable Partners) event. “We analyzed all of our MVPs based on a number of parameters including, but not limited to, collaboration with The Phia Group, beta testing, using of services and products, a willingness to innovate and take risks, a forward-thinking methodology and efforts taken to secure the future of our industry. When we finished our calculations, Diversified Group was a clear winner.” stated Adam Russo, CEO of The Phia Group.

“We are very honored to have earned this recognition from The Phia Group. Empowering plans is the core value we bring to our customers seeking effective alternatives to the traditional carrier based ASO and fully insured plans – the market is hungry for empowerment,” stated Brooks Goodison in response to the announcement.

Furthermore, The Phia Group recently interviewed Brooks Goodison as part of their “Empowering Plans: Best of the Best – Sitting Down with an MVP amongst MVPs” Podcast. This was part of The Phia Group’s “Partners in Empowerment” series. In the episode, which is now available on YouTube, Brooks discusses the industry at large, the appeal as well as the challenges and what makes Diversified Group different than the typical Third Party Administrator.

Diversified Group is honored to see our cutting-edge focus and commitment to full transparency gaining recognition within the self-funded community.

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How a Broken Healthcare System Impacts People’s Lives

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As a Third Party Administrator, employers and plan members count on us to make their health benefits work. While that sounds easy enough, it can be anything but easy when ordinary working families are forced to face exorbitant hospital bills.

One couple recently found themselves confronted with a very difficult situation when their son needed a medical procedure that would be considered routine in ordinary circumstances. However, what happened was anything but ordinary. The hospital rejected the couple’s insurance, saying that because they had gone out of network, they would be required to pay $9,000 up front for their child’s tonsillectomy and another $10,000 or more immediately following the procedure.

Their health plan, which we manage for their employer, has been partially self-funded for several years. In addition, the employer recently replaced their PPO network with reference based (or cost plus) pricing, a strategy that enables the plan to define pricing limits and ensure a much more transparent view of healthcare expenses.

In this particular case, we worked with the parents, their regular pediatrician and ELAP Services to arrange for the procedure to be performed at a local, affiliated surgical center – at a fraction of the price quoted by the original hospital. Their total cost was less than $2,000, approximately one tenth of the cost the original provider intended to charge. It took a great deal of work and cooperation to achieve this outcome, but the case serves as an excellent example of what can be done when a health plan has been designed to encourage open dialogue between patients, trusted advisors and providers.

More and more, hardworking Americans are facing extraordinary healthcare costs and struggling to pay their bills. NerdWallet Health conducted a study and found that a debt collection agency will contact 1 in 5 American adults regarding medical debt. This means there are approximately 51 million people who are unprepared and unable to deal with the rising cost of healthcare.

Another aspect of healthcare that is seldom discussed is the challenge facing small and mid-sized employers struggling to provide adequate healthcare to their workers. Rising costs have made it nearly impossible for many companies to hire new employees or invest in their businesses in other ways. Sadly, millions of Americans have seen their standard of living eroded by the cost shifting that has occurred.

As these parents and their employer have discovered, alternatives like reference based pricing are helping to build bridges between employers and hospitals. “While a good deal of experience is required to design these plans and manage them over time, the opportunity for cost savings is so significant that more and more employers are moving in this direction,” said Brooks Goodison, President of Diversified Group. One of New England’s most experienced Third Party Administrators, Diversified Group has responded to the growing demand. “With or without reference based pricing, Diversified has long been committed to pursuing mutually rewarding partnerships between employers and community-based health care facilities,” added Goodison. “Open communication, cooperation and innovation by businesses and healthcare providers are musts if the issue of runaway healthcare costs is ever going to be resolved.”

As cases like this have long shown, the price for a given healthcare procedure in the same locale can vary greatly, often with little difference in quality. When employers use reference based or cost plus pricing, the plan and area hospitals typically agree on a pricing schedule for covered benefits by using Medicare plus a predetermined margin. Visit Diversified Group online to learn more about reference based pricing and view a brief educational video by ELAP Services, Inc.

How Do We Feel About Disruption in Healthcare?

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If It Helps to Control Costs…We Say Have At It!

While many healthcare providers and insurance carriers are raising concerns about the recently announced partnership by these mega employers, I say Thank You! That’s right – thank you for caring enough about runaway healthcare costs to do something disruptive. For making a commitment to get involved.

Why would an independent TPA applaud when a company that seems to be on a mission to take over the world, and other giant corporations, decide to tackle the healthcare space? Because there are far too many stakeholders accepting the status quo and standing on the sidelines as huge claims are paid without a blink of an eye and the cost of specialty drugs continue to skyrocket.

It’s far too early to tell if the proposed partnership by Amazon, Berkshire Hathaway and J.P. Morgan will lead to lower costs or improved outcomes. But as a TPA who fights to help my clients control costs every single day, I say that if this venture and others can make a positive difference, then have at it. Perhaps this new level of disruption will be just the prescription our ailing healthcare system needs!

Tell Us How You Feel!
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Are Costs Really Beyond Anyone’s Control?

Healthcare CostsIn at least one big city, a major carrier is providing 100% coverage to public employees for MRIs, CT Scans and other imaging services only when free-standing, non-hospital based facilities are used. What do you know? Independent TPAs have been helping self-funded health plans do things like this for years.

Too many people have long considered rising healthcare costs to be a condition we simply must live with. Fact is there are alternatives, most of which can only be implemented when the plan’s best interests are first and foremost.

Detailed Reporting Needed

In contrast to a fully-insured plan or self-funding with a carrier-owned ASO, using an independent TPA enables the plan to make informed decisions based on detailed reporting – reporting that the plan owns.

There is no secret to controlling plan costs. It requires discipline and the tools to monitor individual parts of the plan, such as prescription drugs, imaging, chronic disease management and more. Analyzing expenditures such as these can yield huge savings over the course of a year, but only when your administrator is free of carriers or provider affiliations. Having checks and balances in place can make all the difference.

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Amid Uncertainty in Health Care, the Forecast for Self-Funding with an Independent TPA Remains Very Positive

The 2018 Forecast for TPAs & Self-Funding, recently released by the Society of Professional Benefit Administrators (SPBA), expects factors to fuel continued growth and expansion by TPAs and self-funded health benefit plans in the coming year. The most significant of these factors is a growing demand by today’s workforce for more personalized benefit offerings that help enhance the well-being of younger workers. Fred Hunt, past President of SPBA, describes independent TPAs as creative, flexible and well positioned to respond to rapidly changing needs of plan sponsors and their employees.

A Trusted Authority on Self-Funding

“As an independent TPA with 40 years of experience, Diversified Group has helped thousands of companies enjoy the flexibility and financial control that a partially self-funded health plan can provide,” stated Brooks Goodison, President of Diversified Group. “Our firm is a long-standing member of SPBA because of Fred Hunt’s experience and the unique vantage point the organization provides to the self-funded marketplace.”

As the need for customization and relevant plan data continues to grow, the Diversified Group of companies are uniquely qualified to help employer groups avoid the limitations and rising costs common to off-the-shelf, fully-insured plans. Let our experience in self-funding provide your solution to health benefits.

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